Proceedings of the Standing Senate Committee on
Social Affairs, Science and Technology
Issue 35 - Evidence - May 27, 2015
OTTAWA, Wednesday, May 27, 2015
The Standing Senate Committee on Social Affairs, Science and Technology met this day at 4:29 p.m. to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
Senator Kelvin Kenneth Ogilvie (Chair) in the chair.
[Translation]
The Chair: Welcome to the Standing Senate Committee on Social Affairs, Science and Technology.
[English]
I'm Kelvin Ogilvie from Nova Scotia, chair of the committee. I invite my colleagues to introduce themselves starting on my left.
Senator Eggleton: Art Eggleton from Toronto, deputy chair of the committee.
Senator Merchant: Pana Merchant from Saskatchewan.
[Translation]
Senator Chaput: Maria Chaput from Manitoba.
[English]
Senator Raine: Nancy Greene Raine from British Columbia.
Senator Wallace: John Wallace from New Brunswick.
Senator Beyak: Lynn Beyak from Ontario.
Senator Stewart Olsen: Carolyn Stewart Olsen from New Brunswick.
Senator Seidman: Judith Seidman from Montreal, Quebec.
The Chair: Thank you, colleagues. I want to welcome the witnesses. I will identify them as I introduce them to speak. Since there was no vicious battle to see who will go first, I will call them in the order in which they appear on our agenda.
I remind us all that we are here this evening to continue our study to examine and report on the increasing incidence of obesity in Canada: causes, consequences and the way forward.
With that, I will invite Steve Barnes, Director of Policy with the Wellesley Institute to present.
Steve Barnes, Director of Policy, Wellesley Institute: Thank you, senators, for having us here today. It is a privilege.
I am the Director of Policy at the Wellesley Institute, a Toronto-based nonprofit and non-partisan research and policy institute. We have a mission to advance population health by driving action on social determinants of health and to advance health equity.
I would like to speak today about the way that obesity is commonly seen as a problem connected to individual level behaviours. However, there is extensive evidence that shows that there are connections between obesity and many determinants of health.
Today I will speak about those connections and make brief suggestions about opportunities that exist to move ahead on social determinants of health and obesity. I hope we can have a full discussion.
It is well-known that obesity is a growing challenge in Canada. In 2011-12, one-in-four adult Canadians was obese or overweight. Of particular concern is that the rate of obesity has been increasing. Since 2003, the rate has increased by 17.5 per cent. Childhood obesity is also a significant concern. Almost one third of Canadian children are overweight or obese. This has also been an increasing trend in Canada in recent decades.
The health impacts of obesity are wide and commonly understood, but obesity contributes to increased risks of coronary heart disease, type 2 diabetes, hypertension, stroke, liver and gallbladder disease and some cancers.
For children, the health consequences are even more significant because they last across a lifetime. In addition to cardiovascular disease and higher rates of diabetes, stress and asthma, these conditions not only exist in childhood but become worse and exist across the life course as well. It is estimated that today's children will live three to four years less than today's adults because of obesity.
Of particular importance for our discussion today is the fact that obesity and the risks associated with it are not evenly spread across the population and some populations are at greater risk than others. For example, in Canada lower income is more common among recent immigrants, lone parents, seniors, single adults, off-reserve Aboriginal persons and people living with disabilities.
What I would primarily like to speak to you about today is the opportunities that exist to address obesity by reducing poverty. Poverty affects the ability of individuals and families to provide the basic necessities of life. We all know that. When we think about this from the social determinants of health lens, we are talking about food, housing, child care, recreation — a whole range of things.
Neighbourhood income is an important determinant of obesity and obesity is more common in both men and women in neighbourhoods that have lower socio-economic status.
At the federal level, there are a number of things that can be done to reduce poverty. One of the overarching things that can be done is the development of a poverty reduction strategy which would be in line with what 11 provinces and territories have already either committed to or are in motion on. A number of municipalities are moving on it as well. We can discuss that in more detail later.
There is also a need federally to get more involved in the direct income supports as well. For example, the Working Income Tax Benefit is an important way to provide income support to people who have low income and have paid employment, but it is not set high enough to bring people out of poverty. Similarly, there are opportunities to make progress on EI and CPP and a range of other areas as well.
One area that is particularly important as well is to think about poverty reduction not just as cash benefits. There is a range of noncash benefits that are also important to address social determinants of health.
For example, in any given year one in 10 Canadians will not fill a prescription because of costs. Many of those people will either not take the medication that has been prescribed or will pay out of pocket, which puts pressure on their ability to afford housing, food, and so on. There are opportunities to progress on a national pharmacare strategy, for example, that reduces those day-to-day costs for low income Canadians.
There are other noncash benefits that we can discuss in more detail around things like child care and affordable housing as well.
I will turn briefly to discuss neighbourhood level factors. Health-enhancing environments are more common in areas that are doing better off relatively speaking. That includes neighbourhoods that enhance abilities to undertake physical activity. That is, green spaces, parks, and so on.
At the community level, obesity rates tend to be higher in poorer neighbourhoods. Many of those neighbourhoods also have greater prevalence of fast-food outlets and fewer opportunities to purchase healthy food.
Many of the policy levers in this area exist at the municipal and provincial level but there are opportunities for the federal government to support provinces and cities as they work on this area. For example, the federal government has a lot of power and large capital investments in things like transportation infrastructure to assess the health impacts and to prioritize areas and developments that will have positive health implications.
Finally, I would like to speak about the importance of coordinating efforts. I already noted the importance of working with provinces on their poverty reduction strategies. That is something at the federal level that can be a key priority. Even within the federal government, I think there are opportunities to greater coordinate what is going on across ministries, departments, agencies, and so on.
An approach that has been successfully used in other jurisdictions, including Australia, is a policy model called Health in All Policies, which is as simple as it sounds. You build structures into your policy processes that allow you to assess health using simple tools like health impact assessment to help you make healthy decisions along the policy chain.
I will stop there. I hope we can have a fuller discussion for the rest of our afternoon together. Thank you very much.
The Chair: I will now turn to Valerie Tarasuk, Principal Investigator, Professor, Nutritional Sciences, University of Toronto, with PROOF. I invite you now to present.
Valerie Tarasuk, Principal Investigator, Professor, Nutritional Sciences, University of Toronto, PROOF: PROOF is an interdisciplinary research program funded by the Canadian Institutes of Health Research. Our mission is to identify effective policy interventions to reduce food insecurity in Canada.
"Food insecurity'' is the term that we use now to talk about people that are struggling to put food on the table because of lack of money. The definition we typically use is inadequate or insecure access to food due to financial constraints. It is a profound social determinant of health. That is the point I will address in this presentation.
Our most recent prevalence estimate for food insecurity in Canada comes from the 2012 Canadian Community Health Survey. That year, 12.6 per cent of Canadian households reported some level of food insecurity. The rates vary geographically. They are higher in the North and in the Maritimes, topping out at 45 per cent in Nunavut, but nowhere in Canada do we have a prevalence of food insecurity that even gets as low as 10 per cent.
We talk about food insecurity at the household level because that is how food is bought and shared, but to translate that into numbers that make more sense to you, 12.6 of Canadian households means over 4 million Canadians were affected by some degree of food insecurity in 2012 — over 4 million. That is about half a million more than were affected in 2007. We are moving in the wrong direction. It is also disturbing that one in six Canadian children were living in a household affected by some degree of food insecurity in 2012.
The probability of food insecurity, as you'd expect, rises as income falls, but there are other risk factors for food insecurity: being Black, Aboriginal, having children, being a lone parent mother, being reliant on social assistance or employment insurance. All of those factors increase the probability of food insecurity.
That said, the majority of food-insecure households in Canada defy those risk profiles. Just to give you an illustration of that, almost two-thirds of food-insecure households in Canada are in the workforce. They are reliant on employment incomes but still unable to make ends meet.
Why should we care about this? It is a profound determinant of health. Food insecurity erodes both physical and mental health. It is the single-most potent predictor we have of poor dietary quality in Canada, much better at predicting poor diet quality than either income or education.
I could speak about the evidence or the research linking food insecurity to obesity but, honestly, I have refrained from doing that because it is the least of the problems associated with food insecurity.
Children exposed to severe food insecurity, we have found, subsequently are at higher risk of developing a whole range of chronic conditions, including things like depression and asthma. Adults in food-insecure households are also at much higher risk to develop a whole raft of physical and mental health problems. Once chronic conditions are established, the ability to manage them, as you can imagine, for either an adult or a child in a food-insecure environment is problematic. They are much more likely to manifest with poor disease outcomes.
We have recently been looking at data in Ontario and health care insurance programs. We found that adults in severely food-insecure households, in the course of a 12-month window, utilize about 2.5 times as many health care dollars as those of us in food-secure situations. I offer that ratio to you to highlight two things — both the profound health disadvantage associated with food insecurity but also the extent to which this is a public cost.
What is being done about it? We have yet to see a single public policy at the federal, provincial or territorial level that is designed explicitly to address food insecurity. We have a variety of poverty reduction strategies, and interventions have been mounted ostensibly, in part at least, to reduce poverty among some groups, but their effects on food insecurity, for the most part, are imperceptible. Our primary response to this problem from the outset has been food banks or food charity, and that continues to be our main response.
Two members of the PROOF research group, Lynn McIntyre and Cathy Mah, recently did an examination of federal and provincial Hansard records dating back to 1994. They found several instances where the problem of hunger or food insecurity came up. In the course of discussions where policy was introduced as a result of those concerns, the only kind of policy that has been introduced is policy that fosters food bank donations, things like the Good Samaritan legislation that several provinces introduced. We could find no evidence from this detailed examination of 20 years of Hansard of a time when the problem of food insecurity was taken up as a policy problem with a different kind of approach.
That is concerning because food insecurity is not so much a food problem as it is a problem of material deprivation. By the time someone is struggling to put food on the table for themselves and their family, they are struggling on many other levels. They are very likely to be behind in bill payments. If they have prescription medications, they are likely not to have filled them if they don't have coverage. They are foregoing other necessities and, most concerning, they may be behind in their rent. In short, they are failing to make ends meet and are scrambling to do whatever they can to cope until they get another cheque. Some may turn to a food bank or community program for help in that context, but most don't.
While food banks remain the public face of food insecurity in Canada, the prevalence of food insecurity is many times higher than the number of people using food banks. We have no evidence that the assistance food banks provides is even sufficient to alleviate short-term food shortages let alone actually move people from food insecurity to food security.
The same limitation applies to other sorts of community food programs, such as community gardens, community kitchens or subsidized fruit and vegetable programs that have become so popular. While these initiatives are well intended, they are incapable of altering the material deprivation that underpins food insecurity.
What is needed? Insight into policy solutions comes from looking at a couple of success stories that I think we have. One of them is the poverty reduction strategy that was launched in Newfoundland and Labrador in 2006. As Mr. Barnes mentioned, several provinces have introduced poverty reduction strategies. There is only one that we can see with this kind of impact on food insecurity, though, and I will speak specifically to its impact on social assistance recipients.
About 70 per cent of social assistance recipients in Canada are food insecure, and that is widely understood to be a problem of the very low incomes that are provided to people on those programs. Between 2007 and 2012, the rate of food insecurity among social assistance recipients in Newfoundland and Labrador dropped in half. Why? Well, as part of rolling out their poverty reduction strategy, they raised income support rates, indexed them to inflation, increased the limits for liquid assets and earnings exemptions and increased the low income tax threshold. Taken together, they enabled people on social assistance to retain more income. That had a profound effect on their probability of being food insecure. This is a very important finding because it is proof that changing public policy in a way that improves the material circumstances of very vulnerable groups will change their food insecurity situation.
The other story we have of policy intervention that appears to be a success story is related to seniors. For many years, led mostly by the federal government but also with provincial and territorial involvement, we have seen very aggressive strategies to reduce poverty amongst Canadian seniors, and that has worked. With that, we have also seen much lower rates of food insecurity amongst Canadian seniors. Food insecurity is not zero amongst seniors, but they are the only social group that we can find that appears to be protected from the problem. In fact, when a low income adult turns 65, if they are low income when they turn 65, just by the act of having had that birthday, their risk of food insecurity drops in half.
The defining feature of the two policy examples I have given you insofar as they have had an impact on food insecurity amongst the groups affected has been that they have substantially improved the material circumstances of people at the bottom end, improving both their income and their income security. That is what we think distinguishes these two policy interventions from other sorts of policy interventions that have perhaps had some effect on poverty reduction but actually not a perceptible effect on food insecurity.
In sum, food insecurity is a serious public health problem in Canada. All indications are that this problem is getting worse. It desperately needs to become a public policy priority. That means tackling the material deprivation that defines food insecurity, recognizing that it is more than a food problem. Thank you.
The Chair: Thank you, Dr. Tarasuk. I will now turn to Joe Gunn, who is the Executive Director of Citizens for Public Justice.
Joe Gunn, Executive Director, Citizens for Public Justice: It is a pleasure to be here. Thank you for inviting Citizens for Public Justice to appear before you to speak on this important matter.
Citizens for Public Justice is a national organization that is committed to seeking human flourishing and integrity of creation as a faithful response to God's call for love and justice. We are a faith-based organization. It may be of interest for you to know that we have just done a tour across Canada with leaders of the Mennonite Church in Canada, the Evangelical Lutheran Church in Canada and the head of the Canadian Council of Churches, looking at issues of poverty and climate change right across Canada. We do this kind of work to try to develop just policies that will allow everyone to live in dignity and participate in society.
It is important to be here today because all of us probably know someone close to us, a friend or relative, perhaps a spouse, who is obese or overweight and has suffered profoundly as a result of this. It should come as no surprise to us, then, that the World Health Organization has referred to obesity as a global epidemic and, as Mr. Barnes mentioned already, one in four Canadians are obese, including far too many children.
Unfortunately, perhaps the stereotypes out in the public portray the obese as lazy, fast-food-eating individuals so that obesity has come to mean more or less a moral failure on the part of individuals. I think what you heard from the other interveners today, and you could read in the literature, is that understanding obesity requires more contextualization and that the reality is far more complex than that popular conception, perhaps.
Obesity is a medical condition, but it is also socially and culturally influenced, with attributes defined differently by different people in different places. There is a more medical approach to obesity; you can look at the whole issue of Body Mass Index, which I will not get into. But the reason people talk about obesity as an epidemic is the fast-growing rate of the problems. It has been mentioned that we have had doubling of rates in Canada recently, up to 2008.
Perhaps we need to look at some of the health literature that refers to the popular culprits of obesity as being the "big two'' — poor eating habits and lack of physical activity. But you even get people blaming the Internet, vehicles, remote controls for televisions, lack of physical activity and all these types of things — even sleep debt.
What you will hear from this panel is that we have to move beyond that, and certainly beyond seeing the problem as a matter of personal will.
We would like to join our voice to the argument that poverty is the most significant risk factor for obesity. It's linked to inequality, lower income, increased costs for goods and services and exposure to health risks, such as carcinogens. Obesity is linked to early-life stressors like depression or eating disorders, and there are links between poverty and health which have been pointed out and with which we would agree.
So we need health promotion models that are socially and environmentally connected so that we can address the issue on a social and environmental level. That would be moving beyond food choices and physical activity as perhaps too simple a response and too simple to afford. We need to look for wider changes and move beyond the points of view that would say, "If obese people received correct information, they could change their lifestyle, make better choices and somehow get better on their own.''
We'd like to look at the social and environmental factors of health that would move people to better health through a range of interventions. Our organization, Citizens for Public Justice, has worked since 2009 to co-lead along with Canada Without Poverty, an organization of people who have lived an experience of poverty, a campaign called Dignity for All. It is a campaign for a poverty-free Canada.
Frankly, you, honourable senators, have had a lot to do with the creation of this campaign because the report in December 2009 by this very committee, In From the Margins: A Call to Action on Poverty, Housing and Homelessness, inspired many of us to get out and spread the word among the population. We have worked to develop over the years a number of policy summits with experts and community group leaders. The folks sitting up here have both participated in several of our different sessions. We try to bring people together. As you might know, some of the poverty movement is rather dispersed; some are concerned about housing and others about child poverty. We try to bring people together and develop a plan for moving forward. That is what we would like to do.
I have left copies of the "Dignity for All'' national anti-poverty plan for Canada that we released in February. We now have 15,000 individuals and 600 or 700 organizations that have supported the "Dignity for All'' work. We're just trying to encourage the conversation around what should go forward. Our food security summit heard some of the same witnesses that you heard in April from the First Nations organizations, for example.
We see working toward improving health conditions and empowering communities to gain control over the determinants of health as a political activity that the federal government can play a big role in. We think that the determinants of health refer to poverty, social exclusion and social infrastructure.
There are lots of things that can go forward. If people are not making a living wage, their health will be negatively impacted. If minority groups are discriminated against or socially excluded, their health is negatively impacted. If people are unable to access health and social services, their health could be negatively impacted. So the message of health promotion relies on an understanding of the determinants of health that must be addressed where people work, live and play.
The 2012 study that has already been referred to by someone on the panel is important to look at. It is true in Canada that people living in poverty can double or triple their likelihood of developing diseases such as type 2 diabetes. When obesity and physical activity levels are taken into account, the risk remains high indeed.
I would like to encourage this committee to look beyond perspectives that merely recognize individual or behavioural factors of health and move toward understanding the social determinants of health, which would be crucial, and to emphasize in your work that a national poverty reduction plan is an essential element in the battle against many social, economic and medical ills in Canadian communities, and most certainly in the effort to address obesity.
The Chair: Thank you all. I will now open the questioning to my colleagues, beginning with Senator Eggleton.
Senator Eggleton: This is an important part of our study on obesity. Social determinants of health have been identified in this committee in the past. Mr. Gunn noted one particular study — the In From the Margins report — but there was also the study that Dr. Keon led on population health, which identified the social determinants of health as being quite vital to wellness in our country.
A national poverty-reduction effort with all levels of government being involved is vital to that, as well as policies on the provision of affordable housing. Pharmacare is another thing you mentioned. As well as the food security issues; these are all key parts of the issues of poverty, the issues that lead to health deterioration and the many areas of health deterioration that come about as a result of obesity.
I would like to ask each one of you questions on some specific points. I will start with PROOF. The Newfoundland and Labrador Poverty Reduction Strategy is one you pointed out as having significant value in terms of better food outcomes leading to less obesity. That is a provincial policy. How would you see the federal government being able to work with the provinces or directly to affect that issue to get the kinds of results that Newfoundland and Labrador got in their poverty reduction strategy?
Ms. Tarasuk: I gave Newfoundland and Labrador's strategy as an example because it is one where we see an impact. One other strategy we have been looking at a lot is the Universal Child Care Benefit. There are federal interventions like the UCCB that could potentially have an impact on food insecurity.
We don't see an effect of the UCCB. We have yet to publish on that topic as it has been a source of a lot of work for us. At the same, a post-doctoral fellow who is working on the Universal Child Care Benefit has as his next task Employment Insurance. There are federal programs that have the potential to impact, positively or negatively, household food insecurities.
What we are trying to learn from the example of Newfoundland and Labrador and also from the example of the Guaranteed Income Supplement and OAS for seniors is how to deliver income supplements to marginal groups. In case of EI, a group identified as outside the workforce, or the UCCB, how can you deliver those programs most effectively to impact this problem?
Part of what we are calling for is for food insecurity to be made a policy priority. Part of what you would do when you design something, like the current modifications to the Universal Child Care Benefit, is step back and say, "Will those changes we've made have a palpable impact on this problem?'' If they do, then that would be wonderful. If they don't, then can we do something a little bit different? I think we can.
What made the Newfoundland and Labrador Poverty Reduction Strategy look like none of the other provincial strategies that we examined is the fact that they went down to the depths of poverty and they built those people up. Were we to target a little bit higher benefits in the UCCB for people at the bottom end —
Senator Eggleton: That's what I'm looking for. What are the mechanisms? You mentioned the National Child Care Benefit program for example. The Working Income Tax Benefit could be another. What mechanisms would help the existing programs make a difference if they were enhanced?
Ms. Tarasuk: Yes, the Working Income Tax Benefit is another example. I think these programs have to be enhanced in a way that targets people at the very bottom because people who are not be able to afford to feed themselves and their kids are dirt poor. So rather than setting the targets for poverty reduction that say we're going to change the percentage above a certain threshold that's way up here, if we wanted to tackle food insecurity, we'd say that we are going reach out to those people at the very bottom and make sure that they at least have enough to feed their kids. That means shifting the resources a little bit.
This provincial strategy is enlightening for us, but there are many federal programs in existence that, if we saw them through this lens, could be made better.
Senator Eggleton: Thank you. Let me ask a question of Steve Barnes of the Wellesley Institute. You did a report in 2012, Reducing Childhood Obesity in Ontario through a Health Equity Lens. None of the recommendations, as I understand the report, related to advertising or marketing of unhealthy food to children. Do you have any thoughts on that? It has been mentioned by a number of people who have come before the committee that perhaps that should be banned in terms of advertising. There are different mediums and platforms now than just television, but what are your thoughts on that particular issue?
Mr. Barnes: That's a good question. The report that we wrote back in 2012 was intended to feed into a process that was happening at the Ontario provincial government level where they were working on a Healthy Kids Strategy. That report of the panel that the Ontario government set up came out in 2012 or 2013, and it did make recommendations around limiting advertising toward children. In theory that's not a bad thing to do. I think we can all agree that exposing kids to less advertising, particularly for things that aren't healthy, is a good idea. However, it's area where intervention is still very much focused at the individual level, and it's not going to get at some of the underlying issues that we're trying to get at today. While it may be beneficial to get that kind of messaging away from kids, it doesn't solve the problems around household income.
Senator Eggleton: People just don't have enough money.
Mr. Barnes: Exactly. There are similar questions around things like food education. This is less to do with just children, but there's a stream of thought that goes: If you ran cooking classes for parents for example, they would be able to feed their kids more healthily. This is probably true for some parents, but for many others it's not just a matter of learning how to cook. There's the income poverty that we're talking about, but also poverty of time. It's very time consuming to be poor. When you're working two jobs; you come home; you need to feed the kids; you've picked them up from an unlicensed daycare; rushed them home; and want to get them to bed — that's not the kind of intervention that's likely to be terribly useful. It doesn't mean that you can't do those interventions, but those aren't the ones that are targeting people who are at the lowest levels that Ms. Tarasuk was talking about.
Senator Eggleton: Joe Gunn, your organization advocates for fair taxation. Some witnesses have suggested taxation on unhealthy food or subsidies for healthy food. Do you have any thoughts about that?
Mr. Gunn: It's not something that we've really looked at. We've looked more at trying to work with faith communities, especially to make the argument that there's kind of a sense in the public, encouraged by pro-party programs and so on, that suggest taxes are a bad or evil thing. We've tried to work on the basic issue that a lot of faith communities are helping the poor, organizing food banks and doing all these kinds of things when the problem is bigger.
Really, on the question of taxation of those kinds of products, I don't think we've really moved in that area with any helpful suggestions.
Senator Eggleton: But I think the theme from all three of you is that the income levels need to be improved upon, so people can buy healthy and nutritious foods.
Mr. Gunn: Absolutely. We've also said pretty much the same thing in that when we look at a range of issues, tax measures and so on, we should really look at how they help those who are the most vulnerable in our society.
Senator Seidman: Ms. Tarasuk, it's my understanding that PROOF collects information on the cost and affordability of healthy eating in jurisdictions across the country under the Nutritious Food Basket program. Could you give us some indication of the relative affordability of the Nutritious Food Basket program across Canada?
Ms. Tarasuk: PROOF doesn't collect information on the Nutritious Food Basket. That work is done largely by public health units at least in Ontario and by different groups in different provinces. Our look at the issue of affordability has not been through the lens of food prices. The Food Basket is a list of 67 foods that are costed in stores. Our way of looking at the affordability of food is through Stats Canada which asks people questions about their inability to afford the food they need. That's our lens into the problem.
If you could ask the second part of your question again, though, my guess is I could respond to it. You're asking me about what I think about the affordability of food?
Senator Seidman: Right, and if you could give us some indication about the relative affordability across the country. Are there provincial differences that you're aware of?
Ms. Tarasuk: The big variant in food prices is in Canada's North, but in the South, I'm not aware of large differences in price. One thing that we see when we look at the dietary intake of people who are living in constrained circumstances, so people in food insecure situations, what they stop buying when they stop buying is very predictable. It's tragic, but extremely predictable. If you are struggling to make ends meet the first thing you stop buying is fruit and the next thing would be to limit the purchase of dairy products. Then they start to compromise more basic things like vegetables and protein. Typically people maintain protein and energy or some sort of calories. That's the last to go, but before that they start to take nutritious things out of the basket.
So one of the questions that it brings up for us is that it's not so much the food basket as a whole, but it is these particular commodities. To go back to Senator Eggleton's question: What would be the implications if we made those commodities less expensive? The commodity within that basket that has been most studied from a price perspective is dairy products and that's because of the supply management of milk. For sure, we can see that the particular pricing structure for milk is significant in terms of people making decisions. For example, if we compare food insecure Canadians to food insecure Americans, the Americans have got way better calcium status than the Canadians do. We think that's because, down there, milk is way cheaper and it is probably subsidized through a variety of means. We can see differences.
For me, from PROOF's perspective, where we're doing work on this issue of food costs relative to access, we're looking more at the dynamics within a household's decision-making process and how that plays out relative to price.
Senator Seidman: That's helpful.
Mr. Barnes, you talked in your presentation about there being a growing understanding that complex social and economic problems require integrative and comprehensive policy solutions. You talked about all levels of government being involved.
Could you give us an example or examples of work that you might have done with the provinces and the municipalities that has been successful.
Mr. Barnes: That's an excellent question and one that's very hard to answer because, as we all know, levels of government don't always work together terribly well. I think some of the best examples are actually outside of Canada.
I mentioned briefly work that happened in Australia, specifically on obesity, where they took a "health in all policies'' approach. Of course, the jurisdictional boundaries are a little different in Australia, but in South Australia there was an initiative led by the state government that included the municipalities across the state. They essentially attempted to integrate all of the policy areas that could potentially have an impact on obesity, come up with commonalties and work out where key points of leverage are.
The other thing that works quite well in Australia, and this happened not just at the state level but across a range of governments, is the use of a health impact assessment as a way of understanding the potential health impacts of specific policies. That's used in a much more systematic way in Australia and many European countries than it is in Canada.
The basic premise is that when you're developing a policy, you stop and do a rapid analysis of whether there could be a health impact and for whom. How can we increase the positives and decrease the negatives? If you put an equity lens on top of that as well, you can work out from a population angle more specifically whether, for example, recent immigrants have been disproportionately affected and how you can increase the positives and decrease the negatives.
That approach has happened to some extent in Canada. In Ontario, there is a health equity impact assessment tool that has been used across different ministries in the provincial government. That is a good start, but as far as I know, it hasn't made its way down to municipal-level decision-making, for example.
I'm sorry to speak so much about Toronto and Ontario, but in the city of Toronto the health impact assessment is used fairly often by Toronto Public Health to assess the health impacts of policy decisions that are made across a wide range of city departments. That was a roundabout way of addressing your question, but ultimately what you're looking for is a framework under which this can be tested. It's still early days to know whether this can work in Canada, and Canada has a complicated jurisdictional mix. In your report, you could make the recommendation that we try this for obesity and see how it works.
Senator Seidman: Mr. Gunn, Mr. Barnes mentioned in his presentation neighbourhood factors. I wanted to ask you about that because we've heard a lot in the presentations about the importance of physical activity in obesity. We've also heard that ordinary exercise, out in the neighbourhood activity, is just as valuable, perhaps even more valuable, than organized sports, for example.
I'm wondering if your organization is involved in helping neighbourhoods become friendlier for children in their ordinary daily activities.
Mr. Gunn: Senator, I can't say we're directly involved in that, but among the faith communities with which we work, this is a big issue. We only have to look at the number of summer camp possibilities and who's involved in providing a whole bunch of subsidized possibilities for youth. In the Ottawa area, it's immense.
With some of those opportunities, like Christie Lake Kids here in Ottawa, the organizations that don't have anything to do with faith communities were started that way. There are new Canadians who need those, so things have to change.
We haven't really looked at that issue in a study, to be honest, but I think there's an understanding in communities that finding ways for young people to get out in nature is really important, and finding ways for people to get involved in recreation programs is huge, not just for health reasons, as we know. I'm sorry I can't give you more particulars on that.
Senator Seidman: That's fine.
[Translation]
Senator Chaput: Food insecurity is staggering to me. When I was raising my kids, a little girl used to come over and play with my daughters. She didn't seem poor to me at all, but she told my daughter — and she was three at the time — that they had run out of milk at her house the day before and wouldn't have any more until her mother got paid. And she even went on to say that they drank water because water was good for you.
Hearing you talk about food insecurity, I was reminded of what that little girl had said. I believe that, as a government, we have to come up with a policy to address food insecurity in order to help those who need it most.
How can we help those families and people? Are there any statistics? Do we know where they live and how we can reach them? Do we know what sort of government policy it would take to start at the bottom?
[English]
The Chair: Ms. Tarasuk, do you want to start us off?
Ms. Tarasuk: Thank you for your story. Yes, since 2004 we've been measuring food insecurity on the Canadian Community Health Survey. That's a nationally representative survey of 65,000 Canadians per year run by Statistics Canada. On alternate cycles, there's this very heartbreaking 18-item questionnaire to assess household food insecurity. We have a huge amount of data on this problem.
From my perspective, it's actually very predictable who has this problem. We know that the single biggest driver is low income, but on top of that, to be renting rather than owning your home starts to narrow the scope even more. To be with children, that makes it clearer; to be marginally employed or to be on social assistance, it's quite predictable. I don't think it's a mystery anymore. There's an extraordinary amount of data, and it has taken us a long time to get to the point where the problem is being monitored and measured as well as it is.
Statistics Canada and Health Canada deserve an awful lot of credit for that, but we're at a point where we can identify vulnerable groups with a high degree of probability.
As I said earlier, there are mechanisms at the federal level that could easily be tweaked to have more of an impact for these low-income groups. I also think there is a role for a group like this one in providing leadership in terms of this whole question of accountability. Part of the reason we don't have any public policy on this issue yet is because nobody has asked for it. If we simply made it a mission that we would appraise the strength or the merits of policy interventions based on whether or not they made the situation better or worse, that would be a huge step forward.
Mr. Barnes: I'd like to answer your question about how we reach these people. I think the big mechanism we have is the tax system. One of the big success stories of the Ontario Poverty Reduction Strategy is the implementation of the Ontario Child Benefit. Child poverty actually decreased over the five years of the first strategy. The biggest impact was in the first few years when the Ontario Child Benefit was implemented. It kind of levelled out as time went on, as the Ontario Child Benefit rates held steady rather than increased as planned.
Anyway, the reason that intervention was very important is that it was very easy for low-income families to get. If they filed their taxes, it was determined, more or less, whether you're eligible and here it is. I think one of the lessons we can learn there is we don't need to overcomplicate this. Most of the people we're talking about today will be in some kind of contact with the government at some point over the course of a year anyway. Not everybody files their taxes, and that can be a big challenge, but we know that many low-income people end up using hospitals, emergency departments, and they can actually be an important point of intervention.
It's not perfect because at that stage things have gotten pretty serious. For example, at St. Michael's Hospital in Toronto, they have a program where they actually prescribe income to low-income people who have come into their family health practice. That's the type of thing where they can connect them with people who can do their tax returns and so on.
I think we have to look for those kinds of opportunities that already exist. I think there are opportunities to expand the Working Income Tax Benefit and improve access to EI.
Finally, I would just say the working poor is another area where this is a growing problem. We released a report in February of this year that looked at who has access to employer-provided medical benefits in Ontario, and we found that a third of employees in Ontario have no benefit coverage through their employers, and these people tend not to have access to any kind of public health benefit programs either. We've been looking at opportunities to move on that through the tax system as well.
There are mechanisms that exist, and we need to essentially look for simple places where we can make meaningful interventions.
The Chair: Mr. Gunn?
Mr. Gunn: I would be in agreement. I remember hearing recently on this tour with church leaders of a woman who had been in a situation of violence. She left that difficult situation, came to a city and lived in poverty. She told a story of going to her church and leaving afterwards to go for coffee with friends but crying because she didn't have money to pay for a coffee. Then one day she turned 65 and her life changed.
It's an interesting story. It's not the same story you told about someone not having milk, but we have these kinds of programs in place that are able to help people definitely change their lives. We have to enhance them and make them work, and it is possible. I think part of the difficulty we have is allowing the population to think that we can actually make those interventions work. In the faith communities we often hear, "The poor will always be with you.'' I hate to say the Bible is not correct, but I think it's not actually true.
Senator Raine: Thank you very much for your work. It is very important and it's good that you're sharing it with us.
Mr. Gunn, in your faith-based groups, do you work at all with the Seventh-day Adventists?
Mr. Gunn: We haven't, no. We work a lot with the Christian community because there's a whole history of that, 25 denominations in the Canadian Council of Churches, but I can't think of a time when we've actually worked with the Seventh-day Adventists.
Senator Raine: It strikes me, when I was a young mother with two tiny toddlers moving to a new neighbourhood, within a few days there was a flyer delivered to my house inviting me to come for free cooking lessons at the school at the end of the block. I was new and I didn't know how to cook, so I thought it was a great idea. It was at 8 o'clock in the evening. Great, kids are in bed, I could walk down to the corner to take these cooking classes. It was the Seventh- day Adventists that put the classes on.
I was astonished first of all at the things I learned, but more importantly, I followed this group over the years, and it's a group of Canadians who aren't necessarily wealthy. They're very middle class, ordinary Canadians, but they have virtually no health costs because they cook good, wholesome food themselves.
I appreciate we live in a very obesogenic society and that's not good for everyone, but it would be interesting if we could adopt some of those policies. They were using a lot of foods like beans and grains and things like that that aren't expensive to buy, but you do need to learn how to cook them, and I think we've lost those skills.
Maybe all three of you could comment on whether there are programs or opportunities out there to reteach some good, old-fashioned skills for healthy eating of whole foods.
Mr. Gunn: My best teachers are my children, who are now vegetarians. I'm like you; I've had to relearn a bit of this myself.
In doing this tour across Canada in the last couple of weeks, it was very interesting to see the links that some people are making between climate change issues and our extreme North American diet with so much beef and other types of animal protein. People are actually making the links between being kinder to the earth if we learned to prepare our meals in different ways. That's a challenge for many of us.
I think faith communities have always had laws around dietary kinds of things. Maybe we have to go to the challenge of updating some of them, but there are many programs. I know my own church does this kind of thing as well. There's a feeding program but there's also cooking instruction and so on. Perhaps we need more.
The Chair: Dr. Tarasuk?
Ms. Tarasuk: I think that many Canadians could benefit from more food skills, but I would challenge you around what the problem is that you would want to be fixing. As was said, we've seen lots of initiatives over the last couple of decades launched through health promotion programs and public health, community development initiatives to try to target particularly low-income Canadians and improve their food skills. There is no evidence that we are aware of that low-income people in Canada have lower food skills than the rest of Canadians. It could be argued that they need even better skills to cope with their limited resources, but in fact, that seems to be the case.
If you imagine yourself as a low-income mother struggling to cope month after month, you may not start out being very skilled, but you eventually become an extraordinarily resourceful person. Again, we have data now from the Canadian Community Health Survey on this very point. We can see no evidence that people who are in food insecure situations are less skilled than those who aren't. In fact, the one significant difference we found in that analysis is that they are more likely to work more rigorously with a budget.
As a population overall, with the influx of fast food and convenience foods, there are many things about our food supply that challenge us to be more deliberate in terms of eating whole foods and gaining the skills to prepare them. From the vantage point I have in terms of issues of low income or food insecurity in Canada, I don't think that's the solution.
Mr. Barnes: I think the example you gave is a perfect one of social inclusion. That can have very important health benefits, particularly for mental health but also for physical health, if you move to a neighbourhood and the neighbours invite you to join them in something. That is the type of thing that exists in neighbourhoods everywhere and it's very positive.
I reflect on what Ms. Tarasuk just said around the potential to scale that approach as an intervention against obesity or as kind of a food security issue. One of the interesting things in that regard is that in Canada and many other places, when immigrants arrive, they tend to be, on average, healthier than people born in Canada, although that advantage declines over time.
One of the challenges is that the food environment is so different here. People end up eating more processed foods and different types of foods than what they're accustomed to. I think that type of intervention could actually be very good for social inclusion, feelings of community cohesion, as well as connecting people to cultural resources that actually support and enhance their health.
It is one of those things that is probably better suited to people who are not at the lowest of the income levels. There is a lot of international evidence that shows that interventions that are targeted toward lower-income people often end up reaching the second-lowest income group, which is an important group to reach, but they are the people who can go out at eight o'clock on a weekday night to the local church. It is an important intervention but one that needs to be done alongside others that are targeted toward a higher-need group.
Senator Raine: That is really good.
I can't help thinking that we should be looking at school breakfast and lunch programs, especially in the disadvantaged areas but perhaps everywhere in Canada. For sure it is almost impossible for children to learn when they are hungry at school. If we can give good, nutritious food in our schools, do you think that is something we should be considering?
Mr. Barnes: It is contentious, and this comes up every year in the city of Toronto as they set their budget and they fund or don't fund student nutrition programs. Ultimately, if the question comes down to, will this child eat or not eat today, of course we want school-based programs. It is also an opportunity to have some influence over the quality of the food that children are eating.
Ultimately, though, poor children live in poor families. If we are making sure that kids are eating, I think we also need to be thinking about whether or not the parents are eating. There is evidence that, in Canada, particularly single mothers tend to sacrifice their own eating so that their children can eat. Doing school-based programs might mean that the mom can eat as well, but it doesn't quite get to the underlying issue.
Ms. Tarasuk: I think there are lots of good arguments for putting food in schools, but again I would push back around the fact that we have a very serious problem on our hands with such a high number of Canadian families struggling to put food on the table for themselves and their kids. I would hate for anybody to stop focusing on that problem and move to: We will make sure they have a breakfast before they start school today. Kids are only in school for a few days, only five days of the week. I think it is 192 days a year.
Our neighbours to the south have national school feeding initiatives. There have been evaluations to see what the impact of their national school lunch program is on household food security status, and it is almost imperceptible, because it is a very small infusion of resources to the family.
We have to be careful in going down this path. We have a very serious problem. To move toward a huge infrastructure to put food into schools, particularly recognizing the jurisdictional issues, has an opportunity cost, and I worry that it distracts from the very serious household problem.
As Mr. Barnes said, you will never find a child who has gone without eating unless that mother is extremely hungry, and then to suggest as the solution that we give the child breakfast just doesn't address the problem. We are Canadian; we should be able to do better than that.
Senator Eggleton: There are lots of data, statistics that I have seen on many occasions some of which I've used myself, with respect to the relationship between poverty and poor health, substandard housing and poor health, and many other aspects of that as well. I would like to ask you about the correlation between income level and obesity.
Mr. Gunn, you say in your presentation, "Poverty is identified as the most significant risk factor for obesity.'' You quote Minkler 1999 on that. We all know that not everybody who is poor and in poor health or low income and in poor health is necessarily obese. On the other side, there are a lot of people of higher income who are obese, even though they have the money to buy more nutritious food.
Do you have any information either in support of that statement that I just read or just generally as to the correlation between income level and obesity?
Mr. Gunn: We got this information from the 2012 studies. That is where we saw, in the last page of the document, that folks who were living in poverty during the 12-year study period had a 41 per cent greater chance of developing the disease and obesity when physical activity levels were taken into account. It still remained high at 36 per cent.
I think you asked the right question in the right way by noting that it is not always the case. There are, of course, problems with obesity with people who have good incomes and eat poorly as well.
It does seem that the particular study did point out that there is enough data there to make us want to link this clearly with bringing a good Canadian determination to address poverty, so I hope we are able to do that.
Ms. Tarasuk: The most recent nationally representative study that we have that actually measured heights and weights — I imagine you've already been exposed to it on this panel — was the 2004 Canadian Community Health Survey. In that survey, about 20,000 Canadians had their heights and weights measured, and there was no evidence of an income gradient for obesity or overweight.
When I say that, to be clear on what I mean, we might have expected from literature from the United States, for example, that as income fell, the probability of being overweight or obese would rise. That was not the case. When we look at Canadians, with the best sample we have, a very large sample — and with measured heights and weights, it is important that they be measured. If you look at self-reporting, the picture changes a bit. But the one demographic with the highest rate of overweight and obesity was actually high-income men. So I think this is a tricky situation.
I would say two things, just to reflect on Mr. Gunn's comments. It looks like we need to be cautious about making extrapolations from data from the United States, because the demographic patterning of obesity and overweight is perhaps somewhat different there; and also, it is very much intertwined with race.
If I can move, then, to talk about food insecurity as a marker of economic deprivation: When we look cross- sectionally, the only group for whom we see an association with greater probability of being overweight or obese is amongst adult women. We don't see a relationship for children at a population level and we don't see it for men. If we see anything amongst food-insecure men, it's that they're more likely to be underweight.
Then we have this relationship, though, that persists. As hard as people like me try to get rid of it, we can't. We get a statistical association with food insecurity and obesity amongst adult women, but we have no evidence that the obesity is caused by their food insecurity. When I thought about how to prepare a deputation to this panel, I was struggling to figure out what to do, because I could honestly talk to you for an hour and a half about the complexities of the analysis and the literature on that particular point. I didn't want to go there because I wouldn't get a chance to talk about stuff I thought mattered more.
Adult women who are in food-insecure situations are likely to have been diagnosed with mental illness; they're likely to have metabolic issues, diabetes, hypertension and other sorts of chronic conditions — things that we would expect to correlate with greater probability of excess body weight.
So the relationship is not clear-cut. While there might be a gradient in the United States, we don't have good evidence of that Canada.
One thing to say before I stop is that for sure, if you are someone who is obese and you are in a low-income or food- insecure situation, your ability to deal with that weight is probably zero. In the same way, if you are a smoker in those situations your chances of stopping smoking are pretty small. That's the other side of this. Whatever caused people to get to that point, their rates are not that much higher than everybody else, but their chances of ever losing weight or being able to engage in more health-protective behaviours, if they are struggling to feed themselves and their kids, are probably zero.
Mr. Barnes: When we think about income we typically think of individual and household income. As Ms. Tatasuk was saying, there are not terribly strong connections to obesity at that level. But when you look at the neighbourhood level you can start to see some connections.
There was a study published in the Canadian Journal of Public Health that showed that children growing up in the poorest neighbourhoods had a higher rate of obesity than children in the highest income neighbourhoods. There was about a 10 per cent differential between the two. That's all children, not just the poor kids in poor neighbourhoods. It's all of the children in those neighbourhoods.
That leads us down the path of questioning what it is about that environment that creates greater rates of obesity. Income is most likely part of that but, as I mentioned earlier, poorer neighbourhoods also tend to lack other pieces of infrastructure that enable good health, like sidewalks, parks and places where communities can gather and so on. It's a complex arrangement, but this is why it's important to have a discussion about the social determinants of health because they all interact and interplay with each other.
Senator Eggleton: That's a valid observation.
Senator Raine: Following up on that, you've been talking a lot about Toronto. Have you noticed any differences between urban areas and small- and medium-sized towns and rural areas? Is that being measured by any of you? Not all Canadians live in the big cities.
Mr. Barnes: Yes, and I can't speak directly to the evidence on that. The Wellesley Institute is Toronto based, and our mandate is the Greater Toronto Area. That's where our primary focus is.
To expand on the answer that I just gave, there will not be one-size-fits-all solutions to questions of the built environment. There are large parts of the country where public transit infrastructure is not a viable option and people have to drive to get to places. I understand that.
The underlying lens is that we need to be looking at physical environments and thinking about health and those connections. Often when we're considering neighbourhood-level factors we look at things in discrete terms. We look at whether or not we should put more parking here and whether a restaurant should go in there and so on, without looking at towns or suburbs or neighbourhoods or even streets as a whole. Applying a health lens is important in our planning decisions, right from large cities down to smaller, rural areas as well.
Senator Raine: I read something, and I forget which country it was now, where they limit the number of fast-food outlets in a certain area because they realize that if there are too many it causes problems.
In the city planning in Toronto are they looking at that kind of thing at all?
Mr. Barnes: I don't think there is any thinking around limiting fast food, although I mentioned earlier that lower- income neighbourhoods tend to have greater numbers of those types of fast-food restaurants.
One interesting thing that is happening in Toronto is an initiative run through Toronto Public Health called the healthy stores initiative, or something like that, where essentially they're going out to all different neighbourhoods in the city and going into existing corner stores and working out how to support them in putting fresh fruit and vegetables into their merchandise. That's because so much of what is for sale there is poor quality, sugary, junky food. The infrastructure already exists; there is a shop there. Why not help them to work out how to get better quality food in there?
These types of things are small, local interventions, but for someone who is struggling to get to the grocery store if they don't have a car and the bus doesn't run frequently enough, actually being able to pick up some fresh fruit and vegetables at their corner store that's a five-minute walk away can make a big difference.
Senator Raine: I have another question for Dr. Tarasuk. You had a list of community food programs such as community gardens, kitchens and subsidized fruit and vegetable programs that have become so popular.
If we are going to try to get healthy food into the corner stores, does it make sense to subsidize them for specific, targeted low-income areas?
Ms. Tarasuk: For me the answer to that is a lot like the answer to the school feeding initiatives. If we want to enable people to have the potential to achieve basic prerequisites to health — a healthy diet and physical activity — if we want to create that, then we don't do it with these piecemeal initiatives that are food based.
Senator Raine: You want to do it with guaranteed annual income and things like that?
Ms. Tarasuk: Guaranteed annual income supports, yes. It takes so much work. If I think about some of these community initiatives, it takes so much work to create a structure where you're cutting 10 cents off the price of a head of lettuce. If I think about the people in our statistics on food insecurity, it's not 10 cents that they're missing. It's thousands of dollars that's the gap between where they're at and where they need to be to be a fully functioning member of our society without those kinds of constraints.
Again, I caution that part of it is stepping back and asking what is the problem you are trying to fix.
Senator Raine: Are there others?
The Chair: I think we're going down a line here that we've been covering a bit throughout the course of the day and we're looking at different aspects.
What you have helped us with today, as I bring this to a conclusion, is you have brought a different lens to some of the issues that have been presented to this point. Even though a number of people have pointed out that they believe it's a complex issue, they have focused on that one isolated aspect that could be identified as being something we could zero in on, for example the particular food store available at the end of the block. You've put it into a much broader context, I think in a realistic way.
One thing that struck me, Dr. Tarasuk, is when you mentioned the issue of the old age pension. All of you were in on that. I live in rural Nova Scotia and I can tell you that the appearance of homes in Nova Scotia changes dramatically at age 65. It's a significant kind of situation. It's an absolute case study on the impact of a guaranteed ability to do things over time.
I want to thank you very much for bringing this new — "lens'' is perhaps too strong a term — but new approach to the thinking of the issues that we've been covering all the way along. You've been extremely helpful in terms of encouraging us to look at these issues in these additional fashions. I'm not sure you've gotten us much closer to an absolute solution, but clearly there are some elements of issues that you've been able to help with.
When you were moving away from the idea that it's solely poverty that leads to obesity and so on, I remember reading a number of years ago the concern occurring in China with the significant increase in obesity in young children. That was entirely related, in that study I read, to the actual significant rise in income and the ability to gain that access. We really do need to consider all of these issues.
I want to thank you very much for being here. Once again, thank you to my colleagues for their questions.
(The committee adjourned.)